Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions

Background The number of people living in fragile, conflict-affected, and vulnerable (FCV) settings is growing rapidly and attention to achieving universal health coverage must be accompanied by sufficient focus on the safety of care for universal access to be meaningful. Healthcare workers in these settings are working under extreme conditions, often with insufficient contextualized evidence to support decision-making. Recognising the relative paucity of, and methodological issues in gathering evidence from these settings, the evidence scanning described in this paper considered which patient safety interventions might offer the ‘better bet’, eg, the most effective and appropriate intervention in FCV settings. Methods An evidence scanning approach was used to examine the literature. The search was limited to FCV settings and low-income settings as defined by the World Bank, but if a systematic review included a mix of evidence from FCV/low income settings, as well as low-middle income settings, it was included. The search was conducted in English and limited to studies published from 2003 onwards, utilising Google Scholar as a publicly accessible database and further review of the grey literature, with specific attention to the outputs of non-governmental organisations. The search and subsequent analysis were completed between April and June 2020. Results The majority of studies identified related to strengthening infection prevention and control which was also found to be the ‘better bet’ intervention that could generalise to other settings, be most feasible to implement, and most effective for improving patient care and associated outcomes. Other prioritized interventions include risk management, with contributing elements such as reporting, audits, and death review processes. Conclusions Infection prevention and control interventions dominate in the literature for multiple reasons including strength of evidence, acceptability, feasibility, and impact on patient and health worker well-being. However, there is an urgent need to further develop the evidence base, specialist knowledge, and field guidance on a range of other patient safety interventions such as education and training, patient identification, subject specific safety actions, and risk management.


Supplementary Document
A mixed-methods design based on the Kirkpatrick model was used to evaluate responses to a self-reported questionnaire assessing six key process measures. Learning, behavior, organizational change and facilitators and inhibitors to change were evaluated with questionnaires, interviews and focus group discussion. Findings: -Over half the participants were following the six processes measures always or most of the time: -confirmation of patient identity and the surgical procedure (57%) -assessment of difficult intubation risk (72%) -assessment of the risk of major blood loss (86%) -antibiotic prophylaxis given before skin incision (86%) -use of a pulse oximeter (86%) -counting sponges and instruments (71%). -All participants reported positive improvements in teamwork, organization and safe anesthesia.
-Most participants reported they worked in a helpful, supportive and respectful atmosphere; and could speak up if they saw something that might harm a patient. -Less than half felt able to challenge those in authority. The data were collected and summarised in individual hospitals, where outcome data were automatically calculated on a summary sheet for any given time period. The data was used at a local level to monitor activity and disease patterns, for auditing and to plan local interventions. Findings: -The data informed the National Policy and Plan for Child Health, -The data triggered the implementation of a process of clinical quality improvement and other interventions to reduce mortality in the neediest areas, focusing on diseases with the highest burdens. The child death auditing process was assessed through systematic observations made at each of the weekly meetings using the following standards for evaluation: (1) adapted WHO tools for paediatric auditing; (2) the five stages of the audit cycle; (3) published principles of paediatric audit; and (4) WHO and Solomon Islands national clinical standards of Hospital Care for Children. Findings: -Areas of the process identified for improvement were use of a more systematic classification of causes of death, inclusion of social risk factors and community problems in the modifiable factors, and more follow-up with implementation of action plans -Other areas for improvement were in communication, clinical assessment/treatment, availability of lab tests, antenatal clinic attendance and equipment for high dependency neonatal and paediatric care.
-Many of the changes recommended by audit require a quality improvement team to implement. Audits were conducted using the Joanna Briggs Institute clinical audit tool Practical Application of Clinical Evidence system (JBI-PACES). Post intervention audit, which was a replication of the pre-audit, was carried out from 1 -6 October 1 2012. The results were then used to undertake the Getting Research into Practice (GRIP) program. Findings: -A moderate improvement (29%) was observed on the compliance rate of criteria 1 (sharp containers/safety boxes not filled above the indicated line).
-A significant improvement (20% to 72%) was achieved in criteria 2 (positioning the sharps containers out of reach of children at a height safe for disposal).
-The finding from criteria 3 (sharps containers are positioned where they can be easily accessed) showed a 51% improvement.
-The lowest improvement (4% to 12%) was achieved in criteria 4 (incidence reporting by healthcare workers).
-A 100% compliance rate was achieved in criteria 5 (staff education).
-Moderate improvement was achieved in criteria 6 (used sharps are discarded into sharps containers at the point of use) with an 80% compliance rate. The study evaluated the impact of a criteriabased audit of the diagnosis and management of obstructed labour in a lowresource setting (Tanzania). The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialists for cases that are assigned caesarean section, retraining and supervision on use and interpretation of partograph and, strengthening teamwork between staff. Findings: -Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025).
-Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04).
-Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for c-section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05).
-Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). A before-after cohort study of multimodal intervention to improve incidence of surgical site infections. Four hospitals completed baseline and follow-up. Three provided suitable data. 4322 operations were followed up. Findings: -SSI cumulative incidence significantly decreased post intervention from 8% to 3.8% (p=<0.0001) which persisted in the sustainability period (3.9%) -Substantial improvement in compliance with prevention measures was observed in follow-up and sustainability period - In phase one, partners developed a training package, which was delivered to 87 Portuguese-speaking nurses. In phase two, the refined training was delivered to 36 nurses in Mozambique and recoded by health psychologists. Measures of participant confidence and intentions to make changes to healthcare practice were collected, as well as qualitative data through post-training questions and 12 short followup participant interviews. Findings: -Participants reported high confidence before and after the training (p = 0.25) -Intentions to use calculators to check drug calculations significantly increased (p = 0.031).
-Qualitative data suggested the training was acceptable, enjoyable and led to practice changes, through improved capability, opportunity and motivation. Opportunity barriers to medication safety were highlighted.